approved covid-19 case reporting and tracing plan

ATTACHMENT 1

Overarching Contact Tracing Steps/Proposed Metrics

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Pima County May 20, 2020

Best Practices Contact Tracing Process

Challenges

Identification and notification of cases

with instructions on isolation and

treatment.

Laboratories are providing specimen testing for patients that are not aware of ADHS laboratory reporting requirements, with a delay in notification to provider and patient

Routine education on isolation at time of specimen collection is not documented

PCHD may contact patient first before provider notifies patient of positive test result

Laboratory results transmitted electronically to ADHS with variable degree of lag time

ADHS sends to PCHD with minimal lag time

Limited data set included with report; clinical information including hospitalization information not provided

Case identification impeded by lack of demographic data (phone number, address) requiring PCHD to ‘find’ patient

Once located, contact tracing begins

Interviewing index cases to help identify contacts as well as public gatherings (weddings, funerals) attended, and their risk of exposing COVID-19 to their contacts during their infectious period

Adequate Staffing

Case reluctance in identifying contacts

Inability to easily locate contacts

Case engagement with interview process

Rapidly changing public health guidance (antibody, antigen, PCR testing algorithms)

Usability of Software

Providing notification to contacts of

potential exposure. For each contact,

assessing exposure risk, determining if

they are experiencing compatible

symptoms, and for those symptomatic,

provide testing options and appropriate

referrals. For each contact to the index

case with compatible symptoms, obtain

their close contact(s) name and contact

information.

Adequate staffing for daily 14-day monitoring

Changing public health guidance

Tools and knowledge to assess exposure risk in different populations/cultures

Ability for individual assessment of current symptoms

Need for potential testing and referral

Contact engagement in education

Contact commitment to quarantine if appropriate

Support to meet quarantine needs

Overarching Contact Tracing Steps/Proposed Metrics

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Pima County May 20, 2020

Best Practices Contact Tracing Process

Challenges

Monitoring of contacts, daily reporting on each contact’s symptoms and temperature for 14 days after last contact with the index cases while they were infectious, and referring for testing and care when indicated

Adequate Staffing

MEDSIS not designed for reporting daily contact information

Labor intensive process

Lost to Follow Up without active engagement with Contact Tracer

Incentive for contact participation

Unanswered questions about employment/ unemployment

Proposed Metrics:

1. Case

a. Time to interview from symptom onset and diagnosis

b. Time to interview from date assigned to interview completion

c. Absolute number and proportion interviewed

2. Contacts

a. Median number of contacts elicited;

b. Number of contacts notified

c. Time from exposure/case notification to contact notification

3. Contact Follow up

a. Contacts with daily contact

b. Contacts with symptoms evaluated within 24 hours of symptoms

c. Contacts who complete full 14 day of monitoring

4. Efficacy

a. Number of new COVID -19 cases arising among contacts during self- isolation period

ATTACHMENT 2

COVID-19 Investigation Process

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Pima County Case Investigation & Contact Tracing Plan Modified from Maricopa County Health Department

TRIAGE & CASE ASSIGNMENT PROCESS: Triage Team – triage per the triage protocol

o For the cases that need investigations per the triage protocol, mark all as “active” status & leave case as unassigned o Classify “confirmed” for PCR & “suspect” for antigen

Investigators

o Use the following filter for selecting cases from the MEDSIS queue (TO BE MODIFIED)

o Scroll to the bottom of the queue & select only cases marked as “active” status (some may be classified as confirmed &

some suspect)

1. Investigator receives provider/facility report of positive/presumptive positive COVID-19 o Check for a duplicate case in MEDSIS o Positive reports may be received from IP MEDSIS entry, ELR report, or ASPHL result report o If no lab report is attached or linked per ELR, investigator must obtain the report

2. If case is known to be part of an existing COVID-19 outbreak or cluster

Investigator o Link the case to the correct outbreak in MEDSIS (refer to the COVID MEDSIS Documentation Guide) o Notify the Team of the MEDSIS number & the Outbreak Name o DSO completion may be held for residents of facilities listed in Outbreak Module (OBM), but all other

documentation should be completed per investigator o Staff linked to an existing outbreak will need a standard interview per investigator

Cluster Response Team o Ensure line lists are received & UTD – reach out to facility if line list not UTD o Batch enter DSO information from obtained line lists for residents of facilities

3. Investigator to call case & notify of positive/presumptive positive results

o Obtain the following information (if not entered already in MEDSIS):

Demographic information Name: Gender: DOB: County of Residence/Zip Code: Email: Contact phone number: MR#:

Template information as follows Age: Reporting provider name & contact #: Facility: Onset date: Hospitalization (Y/N & admit dates): ICU (Y/N): Lives or works in congregate Housing (Y/N): History of Diabetes/Cardiac disease/Hypertension/Chronic pulmonary disease/Chronic kidney disease/Chronic liver disease (Y/N): Daycare/school attendee (Y/N) (Name of facility & dates of attendance while potentially infectious): Household contacts & intimate partner (Name & DOB):

Next steps Notified case of positive COVID-19 results & reviewed calculation of home isolation duration Provided home isolation guidance Provided household and close contact exposure information to case Obtained HH & intimate partners & created contact cases Will follow up with case in 14 days to complete HH & intimate partner contact tracing


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CASE INVESTIGATIONS STEPS:

4. Obtain information for each household or intimate contact

5. Utilize the ADHS Case Definition for COVID-19 to determine if case classification based on case interview information and laboratory testing.

6. Send follow up email to case with attachments using the Public Health Notification o Home Isolation Guidance o Quarantine & Social Distancing Guidance o Public Health Statement of Medical Absence form

Note: When attaching the Medical Absence form for your case, be sure to save it as a pdf before sending

7. Fill in DSO in MEDSIS o Consider requesting medical records/contacting hospital IP/contacting ordering provider’s outpatient facility to

complete the case DSO o Children <18 - Please interview parent/ guardian or obtain permission from parent/ guardian to interview minor

Please fill out foster care questions in DSO o Intubated/Hospitalized patients unable to speak

Attempt to fill out the DSO as complete as possible by:

Calling the IP/bedside nurse to obtain next of kin or emergency contact information

Review of medical records

Calling the IP/bedside nurse and asking DSO questions o Cases who do not speak your native language

Please utilize the Language Line to complete interview Must obtain permission from case prior to completing interview with family or friend

8. Investigator to determine if case is high risk or not

o EMS or Healthcare facilities (both inpatient & outpatient) - No exposure notification o Childcare facility exposure - Notify your Investigations Lead o Correctional facility exposure - Notify your Investigations Lead o Workplace/ Businesses- Notify your Investigations Lead o Residential Treatment Centers – Notify your Investigations Lead o Homeless/unstable housing shelter facility exposure - Notify your Investigations Lead o LTCF/Assisted Living/Group Home/Behavioral Health residential facility exposure - Notify your Investigations Lead

and refer to the LTCF Follow Up Process section in this document for next steps LTCF Liaison can assist with training an investigator in this process or to consult on complex situations Verify name and address of facility and unit type Utilize LTCF Guidance for LTCF/Assisted Living/Group Home facilities Utilize Behavioral Health Guidance for Behavioral Health residential facilities

9. Investigator to close and submit case o Follow COVID MEDSIS Documentation Guide (in addition to the Investigation Protocol) for step by step on COVID

documentation.

**If you need a records request done or records pulled from a health care facility send an e-mail to the Investigator Lead with the case number & your requested task.

https://www.azdhs.gov/documents/preparedness/epidemiology-disease-control/disease-investigation-resources/case-definitions.pdf


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HOUSEHOLD (HH) & INTIMATE CONTACTS TRACING: Investigator (NB- THIS FORM MAY BE MODIFIED)

o Gather the information for each household or intimate contact using the Appropriate Form A contact is considered a person who was <6ft for >10mins during the case’s infectious timeframe All contacts can be captured on the same Contact Tracing Fillable Form by making a new tab for each contact

(instructions included on form) o Provide quarantine/home isolation guidance to case to share with their HH & Intimate contacts o Laboratory confirmed, symptomatic contacts should be Epi-linked to the index case o Symptomatic persons without laboratory confirmation with high-risk professions and/or at risk for poor outcomes referred

their PCP or 211 for testing Investigator should assign self as investigator for contacts

o Asymptomatic contacts can be entered & completed per the Contact Tracing Data Entry Team members o Save the completed Contact Tracing Fillable Form to the Index Case’s attachments o Notify Investigator Lead of need for asymptomatic contact entry by emailing with the index case MEDSIS number &

“Requesting contact entry” in the subject line

Contact Tracing Data Entry Team member

o Receives case number & enters contacts o Under Contacts section in MEDSIS Index Case

Click “Add” Enter First Name, Last Name, DOB, and Gender; click “Search” If results found, click the add symbol next to the name, if no Novel Coronavirus case listed OR click the add symbol

next to the Novel Coronavirus case under the name, if listed

o If “No results found” click “New Person”

o Enter Information from the Contact Tracing Fillable Form attached to the index case in MEDSIS. The numbers in the table

correspond to the fields below:


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o Under Case Management: Investigator section

Assign contact to index case investigator (Form row #1)

o Under Patient Details: Phone/E-mail section

Add email in the field below (Form row #10, if obtained)

o Under Case Details: Classification section

Classify as “Confirmed” in local classification dropdown

Mark Investigation Status as “Completed” and add date of completion (date of contact entry)

o Under Case Details: Comments section

Enter the following comments in the text box (copy and paste as needed; example below)

*asymptomatic*

*Phone* OR *Text* OR *Email*

Contact of <<<MEDSIS Number (Form row #1)>>>; quarantine/isolation guidance

provided; informed of monitoring process.


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o Under Jurisdiction section

Click “Submit to ADHS”

LOST TO FOLLOW UP PROCESS: LTF Investigator Process:

Please ensure that we have made every attempt to reach our cases. If you are new to investigations, please ask a more experienced investigator for ideas on how to reach persons/obtain updated contact information. Below is guidance to help with those investigations where interview is unsuccessful after multiple attempts using multiple modalities.

Please ensure you attempt to contact each case by multiple modalities (including calling facilities to determine next of kin and verifying contact information using hospital EMR) over a period of 48 hours after receiving the positive laboratory result.

At minimum, 3 attempts by phone should be made as soon as case is assigned. Multiple call attempts can be made on the same day.

If we are still unable to make contact through this process: send a certified letter with educational materials and the Home Isolation & Home Quarantine & Social Distancing Guidance to the unverified home addresses. Indicate “Confidential” and “Only to be opened by recipient” on the outside of the letter. Request to mail LTF Letters:

Investigator steps –

Ensure at least 3 attempts have been made over at least 48 hours utilizing at least two modalities available (phone, text) per above LTF process

Create the Positive Letter with the case’s name and your e-mail signature

Attach to case

Verify home address is correct in MEDSIS

Consider requesting medical records, contacting hospital IP or contacting ordering provider outpatient facility to complete the case DSO

Send e-mail to Triage Team to request Lost to Follow Up Letter Mailed

Please include LTF in e-mail subject line

Complete case documentation & close case Triage team steps –

Receive e-mail from investigator & reply all to confirm who will complete the task

Retract case & print the attached Positive Letter Template letter

Include the Home Isolation Guidance and Home Quarantine & Social Distancing Guidance with the Positive Letter Template

Indicate “Confidential - Only to be opened by recipient” on the outside of the letter above the recipient’s name

Ensure that a ‘Public Health Barcode’ is attached to the lot of letters that are to be mailed out

Investigator steps --

Add the following note to the case “COVID-19 positive notification and case mediated contact tracing guidance mailed to case.” Under “Case Investigation & Contacts”. Document date written education sent

Notify Team Lead ready to submit case to ADHS

CONSIDER FIELD BASED INVESTIGATION FOR CERTAIN CASES


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DECEDENT REPORTS PROCESS: . Death Review Team will address these reports

Search the case in MEDSIS

Attach the PIR or HRRF report to the case

Mark the case a “died” with the date in the demographics section and mark patient outcome as “died” in the classification section

Re-submit case to ADHS, if previously investigated or assign for investigation, if not completed.

LTCF/ASSISTED LIVING FOLLOW UP PROCESS:

1. Epi Team Lead to request to enter facility into the OBM. o Team Lead will send email to ADHS

Subject Line: New OBM Message to include:

MEDSIS ID, facility name, facility type/ facility address/ phone number (if known) *Limited information requested initially to expedite creation of OBM

2. PHN LTC Team Liaison to reach out to facility to obtain the following information and communicate the

recommendations verbally and via email. Use LTCF/Assisted Living Intake Form (see below) o Resources to be included in the email are: LTCF guidance, HCW Post Exposure Guidance, Home isolation, Social

Distancing Guidelines, Facility Testing request form, CDC PPE optimization web link, proper PPE donning and doffing web link, and the “COVID-19 Line List” Excel sheet to report symptomatic residents and staff with instructs to report back to PCHD per e-mail, blank template letter link at https://www.maricopa.gov/5496/Long-Term-Care-Facilities

o After collecting information, if needed, Investigator and LTCF Liaison or Investigations Lead to discuss the needs, barriers and plan next steps.

o All facility communication should be noted in the OBM notes. o Each associated case be linked to outbreak in MEDSIS. o Copy LTC lead on follow up e-mail to facility so that the OMB can be updated

3. PHN LTC Team Liaison to communicate PPE request instructions directly to facility and the Logistics Team responds

directly with PPE request follow-up information.

4. If testing is requested a. Testing Need Determination – PCHD liaisons determine need, number and training required for facilities they are

assigned to. b. Test Request – Liaisons submit test request form to Test Management Group via email.

i. Test request is entered into Test Request Log and sent to Test Management team (including warehouse) c. Test Delivery and Training

i. Warehouse fills orders. ii. TMT logistics contact sites and coordinate delivery, training, testing and pickup.

iii. Fulfillment documented by EOB on log. d. Liaison Team Updated - Test Kit Distribution log is shared daily at 0830 and 1600 via email to group. e. Test Results – Paradigm:

i. Portal is accessed daily for results and validated by Aggregate Report sent directly from Paradigm; also daily

f. Test Results – TGen: i. TGen sends emails daily with lab results securely accessed through link and bundled by facility

g. Result Response - Liaisons coordinate with assigned sites to manage and mitigate further contagion. h. Additional Supply Request - Each site, once trained, may submit requests for additional supplied for follow up

testing by submitting another test request form.

https://www.maricopa.gov/5496/Long-Term-Care-Facilities

https://www.maricopa.gov/5496/Long-Term-Care-Facilities


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Tracker Review Weekly - Data Management reviews all test requests and results for the week and reports discrepancies or missing information to TM Lead.

5. Epi receives & attaches “COVID-19 Line List” to the OBM. (NEEDS EPI SIGN OFF) *Try to keep the most up-to-date version attached.

6. Epi Team to create contact cases from attached “COVID-19 Line List” a. If an individual is marked as staff on the line list, Cluster Response Team will call the facility and obtain a

contact phone number for the staff and document in MEDSIS. b. Case specific details (e.g. onset, symptoms, comorbidities) for LTCF residents should already be captured

in the DSO from the information in the “COVID-19 Line List”.

7. ASPHL results are received to Data Team a. Data team to update MEDSIS Local Case Classification to Confirmed or Not a Case b. Staff positive cases will be placed back into the COVID-19 Confirmed Unassigned queue for Case

Investigation c. Staff negative results will be communicated to facility by Cluster Response Team d. Resident results will be followed up by the Cluster Response Team with any consultation needed

8. Commercial results of known staff or residents are received to PCHD

a. Commercial lab result received via CDR, ELR, etc. will appear in MEDSIS queue b. Testing Management Team forwards lab reports to LTC Liaison Team. Liaisons report test results to point

of contact at the facilities and update line lists. c. EPI team checks line lists for cross-reference. d. Investigate per normal investigation protocol (for both staff and residents)

*Independent Living is not a congregate setting.

Appendix:

LTCF/Assisted Living Intake Form: LTC/ALF Team Member Liaison: ________________________/Date: ____________ Facility Name: __________________________/Address: _____________________ Contact Info: Name of primary contact: _________________________________ Email: _________________________________________________ Phone #(s): _____________________________________________ Facility Type (check all that apply – many LTCs have multiple service lines):

SNF ALF Memory Care Other (describe):

Total Bed Capacity: ___________

Current Occupancy (%): _________

# of Short-Term residents: _______

# of Long-Term residents: _______

Total # of Staff: ______________ o # of clinical staff: ________ o # of non-clinical staff: _____

Total # of Patients on dialysis: _______


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Facility layout: Please describe the layout of your facility. (Prompts: Are residents in different buildings? Are they on different floors?) Are you currently experiencing staff shortages? (If yes, please describe) Implementation of COVID-19 Infection Prevention Measures:

Visitation restrictions (describe & date implemented):

Suspension of group activities including congregate meals:

Symptom monitoring of staff and residents (describe & date implemented):

COVID-19 PPE Measures (describe & date implemented):

Policy for staff return to work (describe & date implemented):

Enhanced environmental disinfection measures (describe & date implemented)

Protocols for new admissions (describe & date implemented)

Protocols for residents returning to the facility after discharge from a hospital or Emergency Room visit (describe & date implemented)

How patients are transported to and from the facility Testing capabilities:

Do you currently have COVID-19 test kits?

Current criteria for testing?

Where do you send tests?

Do you have staff with training sufficient to administer NP/OP tests?

As you refine your plans to prepare or respond to COVID-19, here are a few things to think about.

Cohorting residents and staffing based on symptoms or COVID-19 status 1. Clean: no symptoms and no exposure 2. Quarantine: no symptoms but exposure (e.g., roommate of case, all new admits) 3. Isolation-symptoms: symptoms but no test results with probable exposure 4. Isolation-positive: COVID-19+ (until recovered regardless of symptoms)

Given the set-up of your facility, do you think you could cohort patients into these four groups? How would you do this? Personal Protective Equipment (PPE) information.

Do your clinical staff use N95s? o Do you have enough o Do you have any strategies for reuse?

What do your staff use for eye protection? (Prompts: Goggles? Face shields?)

Do you have enough gowns? o What kind? (Prompts: Disposable? Cloth? Plastic/other)

Any strategies for dealing with shortages? Consider prioritization and extended use guidelines Email [email protected] to request supplies Continue to order from your regular supply chains

What are you plans to procure additional staffing if needed?

If you are experiencing staffing shortages: Email [email protected] to request assistance in finding qualified personnel.

Have you confirmed DNR status and ensure there are clear Advanced Directives?


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If a resident with COVID-19 is diagnosed in the facility:

Encourage residents to remain in their room - restrict movement except for medically necessary purposes

Implement universal use of face mask while in the facility for staff

Healthcare personnel should wear all recommended PPE (gown, gloves, eye protection, facemask) for the care of all residents, regardless of symptoms. Implement protocols for extended use of eye protection and facemasks.

PPE request for investigation should be requested through EOCTestKits. Maria Chaira will send the request to Miguel Soto and he will pull the items from the warehouse for pick-up by the investigator.

Use designated staff and dedicated non-critical equipment for patient care

Cohorting may be necessary if multiple patients are diagnosed with COVID-19

If possible, designate a ward or section of the facility for COVID-19 patients with dedicated staff.

Implement protocols for having dedicated healthcare personnel caring for cohorted residents with COVID-19.

Environmental cleaning and disinfection – per CDC guidance

Isolate any symptomatic resident and ensure all recommended PPE (gown, gloves, eye protection, facemask) for the care of symptomatic residents

Facility to internally assess PPE supply and fill out PPE survey to initiate the request for PPE. Facility to continue to place PPE orders through normal supply chains.

Provide notifications and weekly updates to residents and their representatives regarding diagnoses of COVID-19 cases and/or identification of clusters of respiratory symptoms within the facility as per CMS guidance.

Continue adherence to recommended ICP practices – Hand Hygiene, use of PPE, and disinfection of environmental surfaces and resident care equipment

Continue to follow MCDPH LTCF Guidance *Please use this template for your initial note in OBM to ensure we have the needed information for all to reference.


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APPENDIX A - COVID-19 TRIAGE PROTOCOL TABLE (SUBJECT TO CHANGE)

Novel Coronavirus (COVID-19) MAY NEED TO BE MODIFIFED

Morbidity Test Performed

Test Results Local Classification

Investigation

Status

Action Investigators

Novel Coronavirus (COVID-19)

PCR (rapid included) OR SARS coronavirus 2 RNA (SARS-CoV-2 RNA,QL REAL-TIME RT-PCR (COVID-19)

Positive/ Detected

New

High priority investigation

Any Investigator on the Positive Case Response team (see daily Round up) – Investigators to pull cases from active unassigned queue


SARS COV-2 Antigen

Positive / Detected

New

High priority investigation

Any Investigator on the Positive Case Response team (see daily Round up) - Investigators to pull cases from active unassigned queue


PCR OR SARS coronavirus 2 RNA (SARS-CoV-2 RNA,QL REAL-TIME RT-PCR (COVID-19) OR

Pan-SARS RNA

Negative/ Not detected OR Pending

Not a Case Complete

Submit to ADHS


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IgM OR Combination IgM/IgG

Positive / Detected

Suspect Complete

Submit to ADHS


IgG Only OR IgM only OR Combination IgM/IgG

Negative OR Indeterminate OR Pending

Not A Case Complete

Submit to ADHS


IgG Only Positive Suspect

Complete Submit to ADHS

approved covid-19 case reporting and tracing plan

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